PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know

PAAS National® saw the number of validation requests/concurrent claim reviews more than double in 2023! OptumRx®, who conducts the majority of these reviews, discusses the Prescription Validation Request (PVR) in their pharmacy manual as follows:

Administrator conducts limited scope prescription validation reviews for quality assurance purposes (“PVRs”), which are distinct from and are not considered audits. PVRs are utilized to verify the accuracy and validity of prescription claim submissions. Claims are monitored daily for appropriateness and potential billing errors and selected for review prior to payment. Network Pharmacy Providers are typically contacted via fax or email and asked to provide photocopies of specific documents and records related to its claims submitted to Administrator.

While they want to skirt audit laws by not calling them an audit, make no mistake – they are audits, and payment is at stake! Besides OptumRx®, we also see claim reviews from Caremark®, Express Scripts®, Humana®, MagellanRx, MedImpact and Prime Therapeutics. Below you can see the top 5 drugs reviewed in 2023 and the top 5 concerns  after reviewing each claim.

Top 5 drugs reviewed in 2023:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

  1. Lantus®
  2. Humalog®
  3. Creon®
  4. Levemir®
  5. Invega®

The top 5 concerns:

  1. Black out acquisition cost and/or profit margin values on the backtag
  2. Document the reason for the cut quantity – auditor will want to know why the pharmacy dispensed less than what was prescribed
  3. A clinical notation is needed and requires 4 elements: Date, who you spoke with and their title, what they confirmed and the pharmacy employee initials
  4. No backtag/sticker attached, typically requested by the PBM and also helpful for PAAS in order to review the billing elements
  5. Verify the quantity prescribed and make a clinical notation on the hard copy – Unit of Measure (UOM) is not specified or doesn’t make sense for the medication ordered

PAAS Tips:

Jennifer Ottman, CPhT